There are 2 forms of conjunctival papilloma, sessile and pedunculated, and they differ etiologically, histologically, and clinically. See BCSC Section 4, Ophthalmic Pathology and Intraocular Tumors, for discussion of the histologic findings.
Human papillomavirus (HPV), subtypes 6 and 11 (in children) or 16 (in adults), initiates a neoplastic growth of epithelial cells with vascular proliferation that gives rise to a pedunculated papilloma of the conjunctiva. A sessile conjunctival lesion, though also usually benign, may represent a dysplastic or carcinomatous lesion, especially when caused by HPV subtypes 16, 18, or 33.
A pedunculated conjunctival papilloma is a fleshy, exophytic growth with a fibrovascular core (Fig 12-3A). It often arises in the inferior fornix but can also present on the tarsal or bulbar conjunctiva or along the plica semilunaris. The lesion emanates from a stalk and has a multilobulated appearance with smooth, clear epithelium and numerous underlying small corkscrew blood vessels. Multiple lesions sometimes occur, and the lesion may be extensive in patients with compromised immunity.
Table 12-1 Tumors of Ocular Surface Epithelium
Figure 12-3 Conjunctival squamous papilloma. A, Pedunculated. B, Sessile.
(Reproduced with permission from Mannis MJ, Holland EJ, eds. Cornea. Vol 1. 4th ed. Philadelphia: Elsevier; 2017:412.)
A sessile papilloma is typically found at the limbus and has a flat base (Fig 12-3B). With its glistening surface and numerous red dots, this form of papilloma resembles a strawberry. The lesion may spread onto the cornea. Signs of dysplasia include leukoplakia (indicative of keratinization), symblepharon formation, inflammation, and invasion. A very rare variant is an inverted papilloma.
A pedunculated papilloma that is small, cosmetically acceptable, and nonirritating may be observed. Spontaneous resolution can occur over many months to years. Surgical excision with cryotherapy or cautery to the base of the lesion is curative in approximately 90% of cases. An incomplete excision, however, can stimulate growth and lead to a worse cosmetic outcome. Surgical manipulation should be minimized to reduce the risk of dissemination of the virus to uninvolved healthy conjunctiva. Adjunctive treatment with topical interferon-α2b or oral cimetidine may be of benefit for extensive or recalcitrant lesions.
A sessile limbal papilloma must be observed closely or excised. If the lesion enlarges or shows clinical features suggesting dysplastic or carcinomatous growth, excisional biopsy with adjunctive cryotherapy is indicated.
Kaliki S, Arepalli S, Shields CL, et al. Conjunctival papilloma: features and outcomes based on age at initial examination. JAMA Ophthalmol. 2013;131(5):585–593.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.